Problem# 5 INEFFECTIVE PERIPHERAL TISSUE PERFUSION R/T EDEMA

Assessment Nursing Scientific

diagnosis Explanation Planning Intervention Rationale Expected
Outcome
S- Ø Short term: 1.Assess the site - to obtain Short term:
O- the patient Ineffective With After 4° of of edema. baseline data The patient shall
may manifest: Peripheral hypertension, nursing and determine have verbalized
Tissue Perfusion the cardiac intervention, the the severity of understanding of
- periorbital r/t Edema system can patient will be the condition. condition and
edema become able to verbalize 2.Monitor I & O - To determine if enumerate
overwhelmed understanding of the Intake is pharmacologic
- bipedal edema because the condition and equal to the and non-
- skin is tight and heart is forced to enumerate output. Thereby pharmacologic
shiny and flaky pump against pharmacologic determining if regimen.
rising peripheral and non- there is still fluid
resistance. This pharmacologic retention.
reduces blood regimen. Long Term:
supply to organs 3.Monitor
- To obtain
particularly the Long Term: patient’s vital The patient shall
patient’s
kidneys. signs have
baseline data
Vasospasm in After 3 days of demonstrated
the kidney nurse- patient 4.Encourage - To promote increased
increases blood interaction, the ambulation as venous return perfusion as
flow resistance, patient will often as evidenced by
leading to a demonstrate possible. absence of
decreased increased edema.
-to promote
glomerular perfusion as 5.Instruct patient
venous return;
filtration. Thus evidenced by to elevate legs
reduce edema
sodium absence of when sitting.
reabsorption and edema.
fluid retention 6.Instruct a low - To reduce
occurrence of
takes place. Due salt low fat diet.
fluid retention
to an increased
permeability,
fluid shifting
occurs from
intravascular to
interstitial
spaces causing
edema.